Addressing complex healthcare problems in diverse settings: Insights from activity theory

Abstract

In the UK, approaches to policy implementation, service improvement and quality assurance treat policy, management and clinical care as separate, hierarchical domains. They are often based on the central knowledge transfer (KT) theory idea that best practice solutions to complex problems can be identified and ‘rolled out’ across organisations. When the designated ‘best practice’ is not implemented, this is interpreted as local – particularly management – failure. Remedial actions include reiterating policy aims and tightening performance management of solution implementation, frequently to no avail.

We propose activity theory (AT) as an alternative approach to identifying and understanding the challenges of addressing complex healthcare problems across diverse settings. AT challenges the KT conceptual separations between levels of policy, management and clinical care. It does not regard knowledge and practice as separable, and does not understand them in the commodified way that has typified some versions of KT theory. Instead, AT focuses on “objects of activity” which can be contested. It sees new practice as emerging from contradiction and understands knowledge and practice as fundamentally entwined, not separate. From an AT perspective, there can be no single best practice.

The contributions of AT are that it enables us to understand the dynamics of knowledge-practice in activities rather than between levels. It shows how efforts to reduce variation from best practice may paradoxically remove a key source of practice improvement. After explaining the principles of AT we illustrate its explanatory potential through an ethnographic study of primary healthcare teams responding to a policy aim of reducing inappropriate hospital admissions of older people by the ‘best practice’ of rapid response teams.

Introduction

In the UK, theories of organisational learning and knowledge management have been particularly influential in recent attempts to reform health and other public services (Office for Public Service Reform, 2002). Theories underpinned by notions of knowledge transfer and/or knowledge translation (henceforth referred to as ‘KT theories’) dominate current approaches to policy implementation, service improvement and quality assurance (Department of Health, 2000, SEHD, 2000, SEHD, 2001a). The applicability and usefulness of these theories are increasingly questioned given the distributed knowledge base, diverse settings and complex, fragmented nature of healthcare work (Marchington et al., 2005, Tsoukas, 1996, Walker, 2007).

In this paper we propose activity theory (henceforth ‘AT’) as an alternative theoretical approach which illuminates the contested, negotiated nature of healthcare policy, management and clinical work and accounts for some of the difficulties experienced with KT-informed policy and managerial practices. We suggest that an activity theoretical approach enables the relations between policy making, management and clinical work to be understood in new ways, revealing the generative potential of tensions between these three interlinked and overlapping areas of practice. Rather than seeking strict conformity to ‘best practice’, AT highlights the value of variation and even contradictions for practice development.

We begin by outlining key features of KT theories and then present AT as an alternative theoretical perspective. We then illustrate the explanatory and practical utility of AT by drawing on an empirical study of collective learning in primary care teams. In particular we show how AT could account for and suggest ways of moving beyond failures of policy implementation that seem paradoxical according to KT.